Neuropati Diabetes - Gea Pandhita

Neuropati Diabetes

Neuropati Diabetesdr. Gea Pandhita S, M.Kes, SpSSMF Saraf RS Antam MedikaNeuropati DiabetesNeuropati = kerusakan saraf tepi (saraf perifer). Neuropati komplikasi yg sering terjadi pada DM tipe 1 dan DM tipe 2Polineuropati tipe Neuropati DM yang paling sering terjadi

Komplikasi Kronis DM1. Macrovascular:A. Coronary heart diseaseB. Peripheral arterial diseaseC. Cerebrovascular disease

2. Microvascular:A. Eye disease: Retinopathy, Maculopathy.B. Neuropathy: sensory, motor, autonomicC. Nephropathy.

Komplikasi Kronis DM3. Other:A. GIT (Gastroparesis)B. Genitourinary (Uropathy, Sexual dysfunction)C. DermatologicD. InfectionE. Cataract & GlaucomaF. Periodontal diseaseG. Hearing loss

PathophysiologyMacrovascular: Atherosclerosis occur earlier in life, more extensive & more sever.Microvascular: thickening of the capillary basement membrane, increased vascular permeability.

Neuropati DiabetesSekitar 30% dari pasien DM.Terkait dengan:lama menderita DM, danderajat pengendalian gula darah.Dapat melibatkan saraf motorik, sensorik, dan saraf otonom, atau kombinasi.

Klasifikasi Neuropati DMA. Somatic 1. Polyneuropathy Symmetrical, mainly sensory and distal Asymmetrical, mainly motor and proximal (including amyotrophy) 2. Mononeuropathy (including mononeuritis multiplex) Klasifikasi Neuropati DMB. Visceral (autonomic)1. Cardiovascular2. Gastrointestinal 3. Genitourinary 4. Sudomotor 5. Vasomotor 6. Pupillary

Gambaran Klinis Neuropati DMSymmetrical sensory polyneuropathy:Gambaran klinis yang sering dirasakan: Berkurangnya persepsi sensasi getar pada anggota gerak bagian ujungGangguan modalitas sensasi yg lain (raba, tekan, nyeri) pada area glove-and-stockingPenurunan refleks fisiologis angota gerak

Gambaran Klinis Neuropati DMSymmetrical sensory polyneuropathy:Kesemutan pada kaki, Nyeri pada tungkai (memberat pada malam hari, & terutama pada bagian depan kaki)Sensasi rasa terbakar pada telapak kaki Hiper-estesia, dan gaya berjalan yang tidak normalKelemahan otot dan mudah capek (kasus lanjut)Perubahan postur jari kaki akibat pembentukan callus

Uji DiagnostikGejala muscle weakness, muscle cramps, prickling, numbness or pain, vomiting, diarrhea, poor bladder control, andsexual dysfunctionPemeriksaan kaki menyeluruhSkin sensation and skin integrityQuantitative Sensory Testing (QST)X-rayNerve conduction studiesElectromyographic examination (EMG)Ultrasound18There are several diagnostic tests that can be used to determine the presence and type of diabetic neuropathy. Reviewing the patients symptoms can help determine if neuropathy is present and to what extent. It is important to remember that all other potential causes of, for example, muscle weakness and numbness, be ruled out before making a diagnosis of diabetic neuropathy.

All patients with diabetes should receive an annual foot exam in which the foot is assessed for skin sensation using a monofilament (Semmes-Weinstein 5.07 (10-g)), skin integrity (calluses and sores, especially between toes), bone deformities or deformities in the foots structure or biomechanics, and vibration perception. Ankle reflexes should also be tested. Quantitative sensory testing (QST) (responses to pressure, vibration, and temperature) should be used to determine loss of sensation or sensitivity of nerves. X-ray can be used to verify bone deformities.

Nerve conduction studies can detect possible nerve damage by assessing the transmission of nerve impulses. Impulses that are slower or weaker than normal may indicate damaged nerves.

EMG, in conjunction with nerve conduction studies, can help determine if there is damage to muscle or nerve by assessing how well muscles respond to nerve impulses.

When autonomic neuropathy is suspected, ultrasound of internal organs such as the bladder can assist in determining if there is any abnormal function or structure to the organ. For example, does the bladder empty completely after urination?

Komplikasi Neuropati DMUlkusCharcot arthropathyDislocation and stress fracturesAmputation Faktor risiko:Peripheral neuropathy with loss of protective sensationAltered biomechanics (with neuropathy)Evidence of increased pressure (callus)Peripheral vascular diseaseHistory of ulcers or amputationSevere nail pathology

20Diminished sensation in the foot can prevent the patient from recognizing painful stimuli resulting from ill-fitting shoes, poor foot hygiene or minor trauma to the foot. Left unnoticed and untreated, these can lead to foot ulcers. Loss of nerve axons in the foot can also lead to muscle atrophy which can, in turn, lead to imbalance and weight shifting that can cause dislocation, stress fractures, and even lead to joint deterioration (Charcot arthropathy).

The combination of poor blood flow to the extremities and loss of sensation in the foot due to nerve damage contribute to the development of ulcers and infections that can lead to amputation. In 2000-2001, about 82,000 nontraumatic lower-limb amputations were performed annually among people with diabetes.

Prioritas pertama dalam mengobati neuropati diabetes adalah untuk menstabilkan kadar gula darah. Oleh karena itu, penderita diabetes harus rutin memeriksakan diri ke klinik atau rumah sakit.

Berhati-hati terhadap kaki penderita diabetes. melindungi kaki dari cedera dengan memakai sepatu yang baik dan nyaman sepanjang waktu. Lakukan perawatan kaki rutin di klinik atau rumah sakit, terutama jika telah terjadi ganguan mati rasa di kaki.

Pengobatan neuropati diabetes ditujukan untuk memperlambat perkembangan penyakit dan membantu mengurangi rasa sakit.

Diagnosis dan pengobatan dini sangat penting. Penatalaksanaan Neuropati DM

People with diabetes should check both of their feet every day.

It is important to check your feet all over, including in between your toes.

If you can't see the bottom of your foot, use a mirror or ask another person to check for you.

Let your doctor or nurse know if you find any:Kemerahan telapak kakiKulit pecah-pecahBengkakSwellingMelepuhPerawatan Kaki DiabetesMenggunakan lotion untuk mencegah kaki kering dan pecah-pecahMemotong kuku dengan baik secara teraturMenggunakan kaus kaki dan sepatu yang sesuai dan nyamanSegera periksa ke klinik atau rumah sakit apabila ada masalah pada kaki25Proper foot care consists of regular foot examinations by a physician to detect early neuropathy and treat existing lesions, as well as daily foot examinations by the patient. Patients should check for dry, cracking skin, calluses, and signs of infection between the toes and around the toenail.

The American Diabetes Association Clinical Practice Guidelines recommend that all individuals with diabetes receive an annual foot exam to identify high-risk foot conditions. This exam should include assessment of sensation, foot structure, vascular status, and skin integrity. Patients with neuropathy should have a visual inspection of their feet at every health care visit.

Kontrol DM kadar gula darah harus selalu dalam batas normal.Kontrol Tekanan Darah.Olah raga teratur.Berhenti merokok.No Alcohol.Pola makan sehat.Menjaga berat badan tetap normal.Kontrol rutin ke klinik atau rumah sakit.

Langkah-langkah mencegah perburukan Neuropati DM:Treatment of Symmetric PolyneuropathyGlucose controlPain controlTricyclic antidepressantsTopical creamsAnticonvulsantsFoot care

27Symmetric polyneuropathy is treated with glycemic control, treatment of pain, and foot care. The DCCT and other studies provide evidence that intensive glucose control is effective in both preventing the development of neuropathy and, to a lesser degree, improving neuropathic symptoms.

Pain can be treated with tricyclic antidepressants such as amitriptyline or desipramine. These drugs are contraindicated in patients with cardiac disease, and in these cases doxepin, trazodone, or paroxetine can be substituted. Nortriptyline can be substituted if cholinergic side effects are present. Topical pain relievers such as capsaicin cream can be added to the antidepressant regimen if pain persists. Anticonvulsants such as carbamazepine, gabapentin, and lamotrigine can be added to the pain relief regimen if the above remedies do not successfully alleviate pain.

Foot care is not only important in the treatment of diabetic neuropathy, it is necessary to prevent amputation. The essentials of foot care are covered in the next slide.

Lifestyle modificationRegular ExerciseHealthyEatingPrevention of DiabetesTERIMA KASIHRS ANTAM MEDIKA - JAKARTA30Symmetric polyneuropathy is treated with glycemic control, treatment of pain, and foot care. The DCCT and other studies provide evidence that intensive glucose control is effective in both preventing the development of neuropathy and, to a lesser degree, improving neuropathic symptoms.

Pain can be treated with tricyclic antidepressants such as amitriptyline or desipramine. These drugs are contraindicated in patients with cardiac disease, and in these cases doxepin, trazodone, or paroxetine can be substituted. Nortriptyline can be substituted if cholinergic side effects are present. Topical pain relievers such as capsaicin cream can be added to the antidepressant regimen if pain persists. Anticonvulsants such as carbamazepine, gabapentin, and lamotrigine can be added to the pain relief regimen if the above remedies do not successfully alleviate pain.

Foot care is not only important in the treatment of diabetic neuropathy, it is necessary to prevent amputation. The essentials of foot care are covered in the next slide.

Asymmetrical motor diabetic neuropathy (diabetic amyotrophy)

Severe & progressive weakness & wasting of the proximal muscles of the limbs (Mainly lower)Severe pain (anterior aspect of the leg), hyperaesthesia & paraesthesiae.Loss of weight ('neuropathic cachexia'). The patient may look extremely ill & be unable to get out of bed. There may be absent tendon reflexes, extensor plantar responses, & the CSF protein is often raised.Some deficits become permanent.Management is mainly supportive.

Mononeuropathy Motor or sensoryPeripheral or cranial nerveUnlike the gradual progression of distal symmetrical and autonomic neuropathies, mononeuropathies are severe and of rapid onset but they eventually recover. Most commonly affected are the 3rd and 6th cranial nerves (diplopia), the femoral and sciatic nerves, median nerve (carpal tunnel syndrome), ulnar nerve, Lateral popliteal nerve (foot drop).

Autonomic neuropathyClinical features 1. CVS: Postural hypotension, resting tachycardia, fixed heart rate.2. GIT: Dysphagia, abdominal fullness, nausea & vomiting, unstable glycaemia, due to delayed gastric emptying ('gastroparesis'), nocturnal diarrhoea faecal incontinence, & Constipation.3. Genitourinary: Difficulty in micturition, urinary incontinence, recurrent infection, erectile dysfunction & retrograde ejaculation, 4. Sudomotor: Gustatory sweating, nocturnal sweats without hypoglycaemia, anhidrosis; fissures in the feet 5. Vasomotor: Feet feel cold, dependent oedema, & bullous formation 6. Pupillary: Decreased pupil size, delayed or absent reflexes to light.

The development of autonomic neuropathy is less clearly related to poor metabolic control than somatic neuropathy, and improved control rarely results in amelioration of symptoms.

ManagementPain and paraesthesiae from peripheral somatic neuropathies1. Strict glycaemic control2. Anticonvulsants (gabapentin, pregabalin, carbamazepine, phenytoin) 3. Antidepressants (amitriptyline, imipramine, duloxetine)4. Opiates (tramadol, oxycodone)

ManagementPostural hypotension: Support stockings, Fludrocortisone, -adrenoceptor agonist, NSAIDsGastroparesis: Dopamine antagonists (metoclopramide, domperidone), Erythromycin.Diarrhoea :Loperamide, Broad-spectrum antibioticsConstipation: laxatives (senna)Erectile dysfunction (impotence): Phosphodiesterase type 5 inhibitors (sildenafil, vardenafil, tadalafil)-oral, vacume, implantation, psychosexual therapy.